Worksheet B Part I

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SOMERSET VALLEY REHAB & NURSING
BOUND BROOK, NJ  08805

Medicare Provider Number: 315002
Cost report status: Settled Without Audit
[Record Code 1031863 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 315002
PERIOD:
FROM 01/01/2011
TO 12/31/2011
 WORKSHEET B PART I
Cost Center Description Net Expenses for Cost Allocation (from Wkst. A, col. 7) Cap. Rel Buildings & Fixtures Cap. Rel Movable Equipment Employee Benefits Subtotal (Sum of cols. 0 - 3) Administrative & General Plant Oper. Maintenance & Repairs Laundry & Linen Service House Keeping Dietary Nursing Administration Central Services & Supply Pharmacy Medical Records & Library Social Service Nursing & Allied Health Education Other General Service Cost Subtotal Post Step-down Adjustments Total  
0 1 2 3 3 A 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
GENERAL SERVICE COST CENTERS                                          
1 Capital-Related Costs - Buildings & Fixtures 491,751 ###                                     1
2 Capital-Related Costs - Moveable Equipment 9,821 ###                                   2
3 Employee Benefits 641,615 ### ### ###                               3
4 Administrative and General 1,047,486 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 250,567 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 37,499 ### ### ### ### ### ### ###                         6
7 Housekeeping 158,976 ### ### ### ### ### ### ###                       7
8 Dietary 475,743 ### ### ### ### ### ### ###                     8
9 Nursing Administration 390,790 ### ### ### ### ### ### ###                   9
10 Central Services and Supply 117,774 ### ### ### ### ### ###                 10
11 Pharmacy 42,084 ### ### ###               11
12 Medical Records and Library 2,231 ### ### ### ### ### ###             12
13 Social Service 107,433 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 126,806 ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 1,616,163 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 55,806 ### ### ### ### 40
41 Laboratory 99,854 ### ### ### ### 41
42 Intravenous Therapy 121,381 ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 557,799 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 346,810 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 89,232 ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 143,746 ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 549,695 ### ### ### ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 37,814 ### ### ### ### 52
OUTPATIENT SERVICE COST CENTERS                                          
60 Clinic 60
61 Rural Health Clinic (RHC) 61
62 FQHC 62
63 Other Outpatient Service Cost 5,521 ### ### ### ### 63
OTHER REIMBURSABLE COST CENTERS                                          
70 Home Health Agency Cost 70
71 Ambulance 26,893 ### ### ### ### 71
72 Outpatient Rehabilitation (specify) 72
73 CMHC 73
74 Other Reimbursable Cost 74
SPECIAL PURPOSE COST CENTERS                                          
83 Hospice 83
84 Other Special Purpose Cost 84
89 Subtotals 7,551,290 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 233 ### ### ### ### 90
91 Barber and Beauty Shop 6,396 ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 7,557,919 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7